38.2-3418.13 - Coverage for the treatment of morbid obesity.
§ 38.2-3418.13. Coverage for the treatment of morbid obesity.
A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing toissue individual or group accident and sickness insurance policies providinghospital, medical and surgical, or major medical coverage on anexpense-incurred basis; each corporation providing individual or groupaccident and sickness subscription contracts; and each health maintenanceorganization providing a health care plan for health care services shalloffer and make available coverage under any such policy, contract or plan forthe treatment of morbid obesity through gastric bypass surgery or such othermethods as may be recognized by the National Institutes of Health aseffective for the long-term reversal of morbid obesity. The provisions ofthis section shall apply to any such policy, contract or plan delivered,issued for delivery, or renewed in this Commonwealth on and after July 1,2000.
B. The reimbursement for the treatment of morbid obesity shall be determinedaccording to the same formula by which charges are developed for othermedical and surgical procedures. Such coverage shall have durational limits,dollar limits, deductibles, copayments and coinsurance factors that are noless favorable than for physical illness generally. Standards and criteria,including those related to diet, used by insurers to approve or restrictaccess to surgery for morbid obesity shall be based upon current clinicalguidelines recognized by the National Institutes of Health.
C. For purposes of this section, "morbid obesity" means (i) a weight thatis at least 100 pounds over or twice the ideal weight for frame, age, height,and gender as specified in the 1983 Metropolitan Life Insurance tables, (ii)a body mass index (BMI) equal to or greater than 35 kilograms per metersquared with comorbidity or coexisting medical conditions such ashypertension, cardiopulmonary conditions, sleep apnea, or diabetes, or (iii)a BMI of 40 kilograms per meter squared without such comorbidity. As usedherein, BMI equals weight in kilograms divided by height in meters squared.
D. The provisions of this section shall not apply to short-term travel,accident-only, limited or specified disease policies or contracts designedfor issuance to persons eligible for coverage under Title XVIII of the SocialSecurity Act, known as Medicare, or any other similar coverage under state orgovernmental plans or to short-term nonrenewable policies of not more thansix months' duration.
(2000, c. 465; 2003, c. 462.)